Frequently Asked Questions

Welcome to the ASPAN’s Clinical Practice Committee “FAQ” page.

Scroll down the page to read answers to some of the most frequently asked clinical practice questions received by ASPAN. These questions will be modified periodically as practice issues change. 

If you do not find the answer to your question, please feel free to submit it to ASPAN's Clinical Practice Network
or post it on the ASPAN Forum.

 Q: What are the requirements for preoperative Pregnancy testing?
 Q: Can a PACU nurse extubate a patient? Must an anesthesia provider be present? 
 Q: Is there an acuity system that ASPAN recommends to help in daily staffing?
 Q: Can a patient ambulate to the car or is it required that we take them out in a wheelchair?
 Q: What is ASPAN’s standard for vital sign frequency in Phase I and Phase II and Extended Care?
 Q: Do all outpatients need to void prior to being discharged?
 Q: Can we put Preop patients in the same area that we have patients recovering from anesthesia?
 Q: What are the differences between Phase I, Phase II, and Extended Observation (Phase III)?
 Q: Can I give oral pain medications in Phase I?
 Q: How long should we keep patients in the PACU after they have received a narcotic?
 Q: Is ECG interpretation necessary in the PACU, along with running and mounting an ECG Strip?
 Q: At what temperature can we set our blanket and fluid warmers?
 Q: What is the national trend for being able to wear personal, home-laundered scrubs to work in the PACU?
 Q: What research has been done on temporal artery thermometers, and how accurate are they compared to tympanic thermometers?
 Q: Regarding the standard about when to implement medical-surgical restraints -- when does the standard apply?
 Q: Does ASPAN have a position on dose ranging of medications? If so, what is it?
 Q: Can LPNs work in the PACU if they are qualified (such as having BLS, ACLS, hemodynamic courses, arrhythmia courses, starting IVs, drawing blood, and working PACU for years)?
 Q: How long do you need to observe a patient who has had reversal of a benzodiazepine with flumazenil (Romazicon)?
 Q: What does ASPAN say about the standards of L&D nurses obtaining and maintaining ACLS certification?
 Q: Looking for a method to calculate IV fluid replacement for children and adults for the NPO hours, operative and post anesthesia period?
 Q: How can patients with multi-drug resistant organisms (MRSA, VRE, etc.) be cared for in PACU? Do they need to be in an isolation room, recovered in the OR, returned to the patient room for Phase I level of care?
 Q: What is the definition for Phase I and Phase II?
 Q: What are the criteria for discharging a patient following spinal anesthesia?
 Q: Must a registered nurse accompany patients being transferred from PACU?
 Q: What does ASPAN say about families visiting in PACU?
 Q: What are the staffing recommendations for Phase I level of care? Is it necessary to have two nurses present?
 Q: How many PACU beds should there be for each OR?
 Q: What are hospital PACUs doing regarding sending patients back direct to ICU from the OR, especially if the patient came from the ICU? If the patient goes back to ICU must a PACU RN recover the patient there?
 Q: Is it necessary for a cardiac rhythm strip to be recorded and placed with the PACU record?
 Q: Looking for guidelines from ASPAN for recommended frequency of vital signs in Phase I level of care.
 Q: What do we need to do to be in compliance with standards for follow-up phone calls after outpatient surgery?
 Q: What are the recommendations for PACU nurses regarding ACLS and PALS?

Q:  What are the requirements for preoperative Pregnancy testing?

A:  To simply answer this, there is no definitive answer to this question. Practices vary from facility to facility, and should be driven by a preoperative testing policy that is developed in conjunction with the anesthesiology department.

American Society of Anesthesiologists

The American Society of Anesthesiologists (ASA) states in its Statement on Routine Preoperative Laboratory and Diagnostic Screening Standard that “No routine laboratory or diagnostic screening test is necessary for the preanesthetic evaluation of patients. Appropriate indications for ordering tests include the identification of specific clinical indicators or risk factors (e.g., age, pre-existing disease, magnitude of the surgical procedure). …. Anesthesiologists, anesthesiology departments or health care facilities should develop appropriate guidelines for preanesthetic screening tests in selected populations after considering the probable contribution of each test to patient outcome. Individual anesthesiologists should order test(s) when, in their judgment, the results may influence decisions regarding risks and management of the anesthesia and surgery. Legal requirements for laboratory testing where they exist should be observed. The results of tests relevant to anesthetic management should be reviewed prior to initiation of the anesthetic. Relevant abnormalities should be noted and action taken, if appropriate.“1  In other words, tests should only be conducted when there is a clinical indication to do so.

Individual Facility Practice
Some facilities have policies that state that all females from menarche to menopause require a pregnancy test. Other facilities state that the only exemptions from being tested are those women who have had sterilization such as a tubal ligation or a total hysterectomy. Still other facilities have a policy that has nursing staff ask the patient if there is any chance that they could be pregnant. If the patient states “no”, they go on the patient’s word and document as such. While many facilities do not require the pregnancy test anymore, many individual anesthesiologists may require one in their specific preoperative orders for a particular patient.

Additional Considerations
Even among individual anesthesiologists, the issue of preoperative pregnancy testing remains highly controversial.  Randomized control trials will never be done due to ethical considerations.2  For this reason, some physicians feel that all patients should be tested.2  But according to some literature, there is insufficient evidence to support that a single exposure to modern anesthetics causes teratogenic effects on a fetus.3  In addition, if all patients are tested, there are concerns related to legal requirements if the patient is a minor, questioning a minor’s sexuality, HIPAA considerations, and also financial considerations.3  Some physicians believe that informed consent of all females to conduct testing is the best option. And some physicians will write the order for preoperative pregnancy testing if their own personal practice patterns dictate that the test is completed, no matter what the facility policy states.

Conclusion
There is no national standard for preoperative pregnancy testing. The ASA Position Statement indicates that the anesthesiologist needs to consider each individual patient, patient needs, and individual risk factors when ordering preoperative tests. Each facility needs to develop their preoperative pregnancy testing policy in collaboration with the Department of Anesthesiology.

REFERENCES

  1. ASA. http://www.asahq.org/For-Healthcare-Professionals/Standards-Guidelines-and-Statements.aspx. Routine Preoperative Laboratory and Diagnostic Screening, Statement on (2008). Accessed July 2, 2011.
  2. Kahn RL, Liguori GA, Stanton MA, Levine DS, Edmunds CR. Letters to the Editor:  Routine Pregnancy Testing Before Elective Anesthesia is Not an American Society of Anesthesiologists Standard. Anesth Analg. May 2009; 108(5): 1716.
  3. Palmer SK, Van Norman GA, Jackson SL. Letters to the Editor:  Routine Pregnancy Testing Before Elective Anestheia is Not an American Society of Anesthesiologists Standard. Anesth Analg. May 2009; 108(5): 1715-1716.

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Q: Can a PACU nurse extubate a patient? Must an anesthesia provider be present?

A:  The answer to the first question is yes, dependent on several things. First of all, are there any restrictions in your state Nurse Practice Act that prohibit nurses from extubating patients? Second, do you have a policy in your department that states whether you can extubate patients in the PACU? And third, do you have an extubation  competency in place that all PACU nurses must complete before they can extubate a patient?

These three items must all be present before you can consider whether or not you can extubate a patient. Most state Nurse Practice Acts are fairly vague when it comes to specific skills. Many practice acts have statements in them saying that the nurse must be “deemed competent” in a skill to perform it. With this criteria met, the next step is to work with your anesthesia department to develop a policy. Extubation policies can be very simple and straight forward, stating that a PACU nurse may extubate a patient once they have been checked off on a unit competency. Or other extubation policies actually include the policy along with the procedure, step by step. And the third piece is to have a competency in place for ensuring that PACU nurses know how to extubate a patient correctly and safely. There are several resources available to assist in developing a competency for extubation. In addition to the extubation criteria and skills needed, the competency should also include what assessments to monitor after extubation, such as hypoventilation, respiratory stridor and post-extubation laryngeal edema, to name a few.1,2,3

The answer to the second question, “must an anesthesia provider be present?”, lies in your policy. Your policy needs to include the criteria by which an anesthesia provider needs to be present. In many facilities, it is not mandatory for an anesthesia provider to be physically present in the PACU when a patient is extubated, provided that the criteria for extubation are very strict and the nurses adhere to these criteria. However, in all situations, there must be someone who can re-intubate the patient should they get into trouble after extubation. In dire situations, the nurse can ambu the patient until an anesthesia provider is available. But this is not ideal nor the safest option for the patient. Again, in most facilities, the practice is to have an anesthesia provider available within a couple of minutes that would be there to re-intubate the patient if necessary.

REFERENCES

  1. American Society of PeriAnesthesia Nurses. A Competency Based Orientation and Credentialing Program for the Registered Nurse in the Perianesthesia Setting. Cherry Hill, NJ:  American Society of PeriAnesthesia Nurses; 2009. Pages 74-78, 92.
  2. Drain CB, Odom-Forren J, eds. Perianesthesia Nursing:  A Critical Care Approach. 5th ed. St. Louis, MO:   Saunders; 2009. Page 433.
  3. Schick L, Windle PE, eds. PeriAnesthesia Nursing Core Curriculum:  Preprocedure, Phase I and Phase II PACU Nursing. 2nd ed. St. Louis, MO:   Saunders; 2010. Pages 581, 677-678, 682, 1366.
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Q:  Is there an acuity system that ASPAN recommends to help in daily staffing?

A:  ASPAN does not have an acuity system, nor do they endorse any particular acuity system. This question is one of the topics posted on the ASPAN Forum, and if anyone does want a more formal system, they may be able to obtain someone’s “forms” by going to the ASPAN Forum.

What ASPAN does do is define factors that should be considered when determining the acuity of a patient. Acuity is defined as the “clearness or sharpness of perception.”1  In the nursing world, acuity is the complexity, time requirements, and interventions needed for a particular patient.

In the ASPAN Perianesthesia Nursing Standards and Practice Recommendations 2010-2012,  ASPAN includes acuity elements when discussing staffing ratios. These can be found in Practice Recommendation 1, Patient Classification/Recommended Staffing Guidelines.2 

In the Preanesthesia area, acuity is difficult to define as these departments function in so many different ways. Some preanesthesia patients may require extensive day of surgery preparation, especially if they are not prepared through preadmission testing or a preoperative phone call. If patients are not prepared prior to the day of surgery, their “acuity” could be considered more intense. If the patient’s history is significant for co-morbidities, this can also raise the acuity. Patients may need assistance changing clothes or ambulating to the bathroom. The patient may require multiple interventions in addition to their history, such as lab work, ECGs, a preoperative block or an epidural placed prior to surgery. All of these interventions may increase the acuity of a patient.2

For the post anesthesia patient, the ASPAN Standards include elements of acuity in the staffing ratios. The general ratio of 1 nurse to 2 patients in Phase I allows for appropriate care based on the complexity and requirements of a particular patient. Acuity in a post anesthesia patient often revolves around the stability of an airway and the level of consciousness. Critical elements must be met for a patient to be considered stable and less acute. The ASPAN Standards define “critical elements” as “report has been received from the anesthesia care provider, questions answered, and the transfer of care has taken place; patient has a stable/secure airway; initial assessment is complete; patient is hemodynamically stable, and patient is free from agitation, restlessness, combative behaviors”2  The Standards further define an unstable airway as “requiring active interventions to maintain patency such as manual jaw lift or chin lift; evidence of obstruction, active or probable, such as gasping, choking, crowing, wheezing, etc.; and symptoms of respiratory distress including dyspnea, tachypnea, panic, agitation, cyanosis, etc.”2

Other elements that should be considered in determining acuity of a patient are pain management requirements, interventions for hemodynamic stability, PONV, restlessness, anxiety, and other interventions specific to the patient’s procedure.

It is difficult to determine a patient’s acuity prior to their arrival to the preanesthesia area or the PACU. We all know that a simple case can come out of the OR as a train wreck or develop problems once they are in the PACU. Consequently, it is difficult to define acuity or use a specific acuity system in the pre or post anesthesia period with any predictability.

REFERENCES

  1. Anderson KN, ed. Mosby’s Medical, Nursing, & Allied Health Dictionary. St. Louis, MO:  Mosby; 1998.
  2. American Society of PeriAnesthesia Nurses. Perianesthesia Nursing Standards and Practice Recommendations 2010-2012. Cherry Hill, NJ:  ASPAN; 2010. Pages 68-72.
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Q:  Can a patient ambulate to the car or is it required that we take them out in a wheelchair?

A:  This question comes up frequently through the questions sent into the Clinical Practice Network.

One of the recommended assessments prior to discharge per the ASPAN Standards is “arrangement for safe transportation from the facility.”1  The Registered Nurse also determines the “mode, number, and competency level” for transport personnel and method of transportation from the facility.1

With these practice recommendations, it is within the RN’s decision-making to determine if a patient can ambulate to the car or should be discharged via a wheelchair. Many patients having general anesthesia may still be drowsy upon discharge and would require a wheelchair. If a patient has only sedation or a monitored anesthesia care procedure they may feel like ambulating to the car. In all cases whether per wheelchair or ambulation, it is important for the nurse or tech to accompany the patient. Again, per the ASPAN Standards, the RN determines the mode of transportation from the facility as well as the competency level of the accompanying facility personnel.1

Often, having a patient ambulate to the car is a way to assess the steadiness of a patient and how they will do at home. Part of the regular discharge instructions should include having someone with the patient the first few times they ambulate at home. But if necessary, additional instructions can be given for safe ambulation at home when they are being escorted to the car. These instructions may include getting up at intervals and walking around their kitchen for example, to get their “sea legs” back. If a patient has had local infiltration into an inguinal hernia site for example, ambulation is important before the patient is discharged in order to ensure that the local anesthetic did not affect their lower extremities, and therefore their ability to ambulate. If a patient has had a laparoscopic procedure, ambulation may enhance elimination of the carbon dioxide used in the procedure. Ambulation also enhances oxygenation and elimination of the inhalation anesthetics.

Other patients may require a wheelchair. Lower extremity orthopedic procedures, the elderly, those patients still a little drowsy, or if the exit door is a long way from the recovery area may require the use of a wheelchair to safely discharge the patient.

In the end, the decision ultimately falls within the policy and procedure of the facility as to whether patients must be discharged via a wheelchair. However, the ASPAN Standards allow the registered nurse to use his/her assessment and clinical judgment as to the mode of discharge for the patient. This decision could be discharge per a wheelchair or by ambulation.

REFERENCES
  1. American Society of PeriAnesthesia Nurses. Perianesthesia Nursing Standards and Practice Recommendations 2010-2012. Cherry Hill, NJ:   ASPAN; 2010. Pages 77, 89-91.

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Q:  What is ASPAN’s standard for vital sign frequency in Phase I and Phase II and Extended Care?

A:  This question comes up almost weekly through the questions sent into the Clinical Practice Network. In fact, this question is asked so frequently, that we decided to see if there was any evidence out there and brought this all to the Standards revision meeting last fall.

Team leaders from the Standards and Guidelines Committee, along with members from the Evidence Based Practice Committee met face to face in October 2009. In preparation for this meeting, the question to the Evidence Based Practice Committee was “How often should vital signs be taken?  521 articles were reviewed by this team, including 2 abstracts. Rankings and consensus were completed. No evidence, none, was available to guide the practice of how often to take vital signs in promoting optimal outcomes.1

The discussion continued. Perianesthesia nurses want to know what is best practice related to vital sign frequency. Clinical judgment is the essential element in determining frequency of vital signs. Expert opinion from perianesthesia nurses indicates that most units take vital signs every 5 minutes for the first 15-30 minutes of patient stabilization and then go to every 15 minutes for the duration of the patient’s Phase I stay. If the patient is put into a holding pattern, for example waiting for an inpatient bed, the frequency of vital signs can go to the floor standard. For Phase II, expert opinion indicates vital signs every 30-60 minutes to include an admission and discharge set of vital signs.1

Because of this discussion, and the lack of evidence and specific literature stating what the vital sign frequency should be, the ASPAN Perianesthesia Nursing Standards and Practice Recommendations 2010-2012, Practice Recommendation 2, states the following:

“There is no evidence based research available to indicate best practice for frequency of vital signs. Therefore, this should be determined by each individual facility.”2 

Expert opinion states that vital signs should be taken every 5-15 minutes during initial stabilization and more frequently if clinically indicated.

REFERENCES

  1. American Society of PeriAnesthesia Nurses. Standards and Guidelines Meeting minutes, Batesville, Indiana. October 23, 2009.
  2. American Society of PeriAnesthesia Nurses. Perianesthesia Nursing Standards and Practice Recommendations 2010-2012. Cherry Hill, NJ:  ASPAN; 2010. Page 78.

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Q:  Do all outpatients need to void prior to being discharged?

A:  This question has been debated since the advent of ambulatory surgery over 20 years ago. Varying opinions continue on whether patients should void prior to discharge. At this point in time, there is little research and evidence that points one way or another. If the patient does not void prior to discharge, does this alter the outcome for them? Or, is requiring the patient to void an unnecessary practice that just prolongs their hospitalization and adds to their bill?1

Post anesthesia patients are often not well-hydrated when they arrive in the PACU. This results from their NPO status, limited amounts of intravenous fluid, and third spacing, even in routine, seemingly small procedures. These patients have not had time to produce adequate urine. Another factor to consider is that most people void every 4-6 hours. This amount of time may not have passed by the time they are ready to be discharged. Couple that with the potential dehydration, and they do not have enough urine to stimulate voiding.

On the other hand, certain conditions may predispose a patient to urinary retention, such as prostatic hypertrophy. Some surgical procedures may stun the bladder or the nerves surrounding the bladder. Urological procedures may result in hematuria with the potential for clots which may obstruct urinary flow. Other procedures at risk for urinary retention include rectal procedures, inguinal herniorrhaphy, and lower abdominal and pelvic procedures. These patients often do have the urge to void because of manipulation of the nerves surrounding the bladder, and consequently may be at higher risk for urinary retention. Therefore, voiding under these conditions is advisable, according to experts.1, 2

Spinal and epidural anesthesia is another factor to consider when determining if a patient should void prior to discharge. The reverse order of the blockade is motor, sensory, and then sympathetic. The sympathetic nervous system controls bladder function. So the ability to void indicates total resolution of the block. Prior to this, patients cannot tell if their bladder is distended.1,2 

Many PACUs now have bladder scanners as standard equipment. This tool can be used in conjunction with other assessments to evaluate patients for bladder volume and potential urinary retention prior to discharge home.3  In addition, if not requiring a patient to void, patients and their care providers should be instructed on symptoms that might indicate a full bladder, the importance of avoiding over distention of the bladder, and how long to wait before seeking care for a full bladder.4

REFERENCES

  1. Burden N, Quinn D, O’Brien D, Gregory-Dawes B. Ambulatory Surgical Nursing 2nd ed. Philadelphia, PA:  WB Saunders; 2000.
  2. Schick L, Windle PE, eds. PeriAnesthesia Nursing Core Curriculum:  Preprocedure, Phase I and Phase II PACU Nursing. 2nd ed. St. Louis, MO:  Saunders; 2010.
  3. Feliciano T, Montero J, McCarthy M, Priester M. A Retrosective, Descriptive, Exploratory Study Evaluating Incidence of Postoperative Urinary Retention After Spinal Anesthesia and Its Effect on PACU Discharge. Journal Of PeriAnesthesia Nursing, 2008; 23(6): 394-400.
  4. Drain CB, Odom-Forren J, eds. Perianesthesia Nursing: A Critical Care Approach. 5th ed. St. Louis, MO:  Saunders; 2009.
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Q:  Can we put Preop patients in the same area that we have patients recovering from anesthesia?

A:  This question comes up frequently in the clinical practice network. Many nurses that ask this question work in facilities where the staff members of preop and PACU may be one and the same. The question may also come about later in the day when facilities are trying to make the most of the staff they have available.

Standard II, Environment of Care, in the ASPAN Perianesthesia Nursing Standards and Practice Recommendations 2010-2012, states that “Preanesthesia patients are separated from patients undergoing procedures and/or recovering from anesthesia/sedation.”1 

In addition, this requirement for separation comes from the Centers for Medicare and Medicaid Services (CMS). “The conditions for coverage at 42 CFR 416.44(a)(2) state that an "ASC must have a separate recovery room and waiting area.” We consider a "recovery room" to be an area where patients are brought to recover from procedures and are not yet discharged. A "waiting area" is considered to be the area set aside for patients and families outside of the areas used to prepare patients for their procedure, the procedure area itself, or recovery from their procedure. Each ASC must have a distinct "waiting area" and distinct "recovery room" that are not used by patients for other purposes. Medicare regulations do not address specific requirements for a preop area.” 2

The implementation of this requirement can take several different forms. The most common scenario involves a setting where the number of staff is decreasing for the day and it is desirable to combine resources. In this case, preoperative patients may be in the same physical space as patients recovering from anesthesia or sedation. But they should be cohorted and separated as far away as physically possible from post anesthesia patients. Curtains should be used for privacy for the patient and family, and the level of noise should be kept down in the post anesthesia section of the room, so that patients waiting for their procedures do not hear activity related to patients waking up. It is also desirable to have separate staff, that is, a preop nurse is not also caring for a post anesthesia patient. These methods will allow for meeting the standard, as well as practical use of resources and the appropriate environment for the patient.

REFERENCES

  1. American Society of PeriAnesthesia Nurses. Perianesthesia Nursing Standards and Practice Recommendations 2010-2012. Cherry Hill, NJ:  ASPAN; 2010. Page 15.
  2. Pelovitz SA. Clarification of CMS Policies Regarding Ambulatory Surgical Centers.  Centers for Medicare and Medicaid Services. Baltimore, MD. 2002. Available at: http://www.cms.hhs.gov/SurveyCertificationGenInfo/downloads/SCLetter02-16.pdf. Accessed February 28, 2010.
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Q:  What are the differences between Phase I, Phase II, and Extended Observation (Phase III)?

A:  This is a very frequent question that comes through the Clinical Practice network. The questions range from “What are the differences between Phase I, Phase II, and Phase III?” to “Can I get a patient up in Phase I?” to “Can I discharge a patient home from Phase I?”

The ASPAN Standards define Phase I, Phase II, and Extended Care (Extended Observation / Phase III) as levels of care, not physical places. Therefore, the care that is provided is dependent on where the patient is in their physical recovery, not the physical location that they are in.1

Phase I is the level of care in which close monitoring is required, including airway and ventilatory support, progression towards hemodynamic stability, pain management, fluid management, and other acute aspects of patient care. When the patient has progressed beyond these elements of care, they can progress to Phase II level of care. Phase II is the level of care in which plans and care are provided to progress the patient home. This may be in the same location as Phase I care. Many PACU’s are providing blended levels of care, in which all levels of care are provided in the same location. This is often done for staffing reasons or for continuity of care. So if a patient is ready to go the bathroom and is awake and stable enough, they are not necessarily a Phase I patient anymore. They have progressed to Phase II level of care, even if they are in the same location. The same goes for discharging a patient home from Phase I. If a patient is ready to go home, they have progressed beyond Phase I level of care, into Phase II level of care, and may go home if they meet discharge criteria. Again, the Phases are NOT locations, but LEVELS of care.

Extended Care, previously Extended Observation / Phase III, may also be done in the same physical location as care provided to Phase I and Phase II patients. This phase is for patients who have met criteria to leave Phase I, but are not able to go to another place. The most common reason for this is that there is no floor bed. In this case, the patients may stay in the same location as where they received Phase I level of care if there is no where else to move them. The difference is that these patients are basically a medical-surgical patient at this point, and the assessments and care that is required would be different. The staffing expectations would also be different as defined in the ASPAN Perianesthesia Nursing Standards and Practice Recommendations 2010-2012, Practice Recommendation 1.1

The elements to consider for assessments as well as discharge from Phase I, Phase II, or Extended Care levels of care can be found in the ASPAN Standards, Practice Recommendation 2.1   These elements are what determine the phase of care that the patient is in, and if they are ready to progress to the next level of care, no matter where the location of care may be.

REFERENCES
  1. American Society of PeriAnesthesia Nurses. Perianesthesia Nursing Standards and Practice Recommendations 2010-2012. Cherry Hill, NJ:  ASPAN; 2010. Pages 68-78.

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Q:  Can I give oral pain medications in Phase I?

A:  The simple answer to this question is yes. The belief that oral pain medications are reserved for Phase II PACU or for when the patient reaches the postoperative floor is one of those sacred cows that are often found in PACUs.

Many years ago, when anesthetic agents had a longer duration, the inhalation agents given were stronger and more often caused nausea and vomiting in the post anesthesia patient, oral pain medications were avoided for a reason. Patients were not usually awake enough, nor did they feel well enough to take oral medications while in Phase I PACU. The post anesthesia nurse avoided giving oral medications as well as any oral fluids in order to prevent postoperative nausea and vomiting (PONV).

With the advent of propofol and newer inhalation agents such as Sevoflurane and Desflurane, patients are quicker to awaken, often have little or no nausea, and are ready for oral fluids and medications in Phase I. In addition, many patients have been pre-treated with antiemetics due to an increasing awareness of best practices related to treating PONV.1  Patients can be given ice chips, juice or soda if awake enough, and these interventions are also helpful in hydrating the patient sooner.

Another advantage of giving oral pain medications in Phase I is to evaluate the patient that is going home. By giving the oral pain medication in Phase I, which is usually their home prescription medication, along with some crackers or other light food, the nurse allows time to evaluate whether the oral pain medication will work for the patient. In addition, there is time to see if the patient may have an adverse reaction to the medication if they have not had it before. Timing the oral medication shortly after the last IV dose of narcotic allows time for the medication to start taking effect before the IV dose completely wears off. The patient can then be transferred to Phase II level of care for further care, observation, and discharge instructions.

Oral medications do have a place in the Phase I PACU. Each patient should be evaluated for this intervention, as it can be an effective method to transition the patient to the next level of care. 

REFERENCES

  1. American Society of PeriAnesthesia Nurses. Perianesthesia Nursing Standards and Practice Recommendations 2010-2012. Cherry Hill, NJ:  ASPAN; 2010. Pages 68-78.
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Q:  How long should we keep patients in the PACU after they have received a narcotic?

A:  When evaluating a patient for discharge from Phase I or Phase II after a narcotic, several factors need to be kept in mind. These factors include what is the dosage, what is the route, what is the onset of action, when does the drug’s action peak, what is the duration of the drug, and what is the half-life of the drug.

With IV drugs, obviously the drug will have a quicker onset and a shorter duration of action. Most IV drugs, including Morphine, Dilaudid, and Fentanyl, have an onset of action of 1-5 minutes, and peak within 5-20 minutes. The duration of action with Morphine and Dilaudid is 2-4 hours, while the duration of action of Fentanyl is 30 minutes to 1 hour. Morphine and Fentanyl have a half-life of 3-4 hours, while Dilaudid has a half-life of 2 hours.

Oral narcotics have an onset of 30-60 minutes, and peak in 60-90 minutes.

With this information in mind, the nurse must consider what is safe in terms of when the patient can transition to the next level of care. Since the IV drugs peak in 5-20 minutes, it is prudent for the nurse to assess the patient during this period of time, in which time any adverse respiratory effects would occur. It is also a time in which the nurse should monitor the patient without any stimulation in order to see how they may respond when they return to a patient room where it is quiet without PACU stimulation. Patients will generally desaturate when unstimulated, and ensuring that the patient can handle a narcotic without oxygen desaturation is a key component of when it is safe to discharge a patient.

With oral narcotics, the nurse should ask the patient if they have received the narcotic before, and if it was effective for them. If so, then the nurse can give the patient the narcotic with relative reassurance that the patient will be safe, and that the narcotic will work for them. If the patient has not received the oral narcotic before, then the nurse can give the narcotic just prior to transitioning them to Phase II. This will allow time for the narcotic to take effect, generally in 30-60 minutes, and the nurse can evaluate whether this narcotic will be effective for them as well as monitor for any adverse reaction to the drug.

So with this information in mind, what is the time frame for discharge after narcotics?  With IV narcotics generally peaking in 20 minutes along with any adverse respiratory effects, 30 minutes is generally a safe time to discharge the patient from Phase I. With oral narcotics, the nurse will see the effectiveness of the medication within 30-60 minutes, and the patient can transition to home. These time frames allow the patient to progress to the next phase of care in a safe and effective manner.

BIBLIOGRAPHY

  • Drain CB, Odom-Forren J, eds. Perianesthesia Nursing: A Critical Care Approach. 5th ed. St. Louis, MO:  Saunders; 2009.

  • Physicians Desk Reference. 2011.

  • Schick L, Windle PE, eds. PeriAnesthesia Nursing Core Curriculum:  Preprocedure, Phase I and Phase II PACU Nursing. 2nd ed. St. Louis, MO:  Saunders; 2010.

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Q:  Is ECG interpretation necessary in the PACU, along with running and mounting an ECG Strip?

A:  The ASPAN Perianesthesia Nursing Standards and Practice Recommendation 2010-2012 speak to assessments that should be done in Phase I PACU. The Standards state in Practice Recommendation 2 that “Cardiac monitor rhythm is documented per institutional protocol.”1

Many experienced nurses can look at a monitor and quickly tell what rhythm is displayed. However, in order to accurately interpret the rhythm it is necessary to calculate the PR and QRS intervals, along with the rate. This can only be done by running the strip and doing the measurements. “Mounting a strip” is an individual facility policy, but many facilities still subscribe to the motto that if it’s not documented, it’s not done. Stating what the rhythm is in one’s nurses notes is fine, but the “proof” is not in written words, it is in the visual documentation of the actual ECG strip. 

With electronic documentation, many ask, “where do I put the strip?”  The best advice is to use a blank sheet of paper for mounting, if there is no hard copy of the PACU record.

Another frequently asked question is why ECG rhythm interpretation is even necessary. “We just need to be able to tell that something isn’t right” some nurses say.

As critical care nurses, we need to be able to accurately assess our patients, and then share that information with the anesthesia provider. As perianesthesia nurses, we should know that the anesthetic agents all affect the cardiac muscle and can slow cardiac conduction and/or cause increased ventricular excitement. Other anesthetic drugs, such as catecholamines and anticholinergics can alter the balance between the sympathetic and parasympathetic nervous systems. Lighter anesthesia during emergence can cause cardiac dysrhythmias. Research indicates that about 60% of all patients undergoing anesthesia develop some type of dysrhythmia in the perianesthesia period.2 

Fluid status affects heart rate and rhythm. One of the most common causes of tachycardia in the PACU is hypovolemia. Premature ventricular contractions are often a sign of hypoxia in the PACU patient. Pain and bleeding can affect cardiac rate and rhythm as well. The perianesthesia nurse must recognize the rhythm and intervene appropriately. Often the interventions can be done without additional physician’s orders.3

Along with respiratory assessment and airway management, cardiac assessment is one of the most important elements of our practice as perianesthesia nurses. Hemodynamic stability is an element of safe discharge. Thorough cardiac assessment, including interpreting the ECG rhythm, is one of the best ways to assess what is going on with our patients.

REFERENCES

  1. American Society of PeriAnesthesia Nurses. Perianesthesia Nursing Standards and Practice Recommendations 2010-2012. Cherry Hill, NJ:  ASPAN; 2010. Page 75.
  2. Drain CB, Odom-Forren J, eds. Perianesthesia Nursing: A Critical Care Approach. 5th ed. St. Louis, MO:  Saunders; 2009. Pages 148-169.
  3. American Society of PeriAnesthesia Nurses. A Competency Based Orientation and Credentialing Program for the Registered Nurse in the Perianesthesia Setting. Cherry Hill, NJ: American Society of PeriAnesthesia Nurses; 2009. Pages 101-129.

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Q:  At what temperature can we set our blanket and fluid warmers?

A:  The Emergency Care Research Institute (ECRI) just recently changed its recommendations for cabinet blanket warmers.  Cabinet blanket warmers can now be set up to 130º F (54ºC). Fluid warming cabinets should continue to be limited to 110º F (43ºC).1

The change in the recommendation came from recognition in the healthcare community that blankets and fluids should be warmed separately. The original recommendations from ECRI in 2005 for 110º F for both blanket and fluid warmers were based on information that many facilities had been combining blankets and fluids for warming. Consequently, because of this dangerous practice, some patients acquired burns from the fluids, which hold a lot more heat and present a greater burn risk. Therefore, to provide safety for all patients, in 2005 the ECRI recommended the lower temperature of 110º F for both blankets and fluids.1

Further discussions with healthcare facilities over the past several years have indicated a growing awareness and recognition for warming to occur separately for blankets and fluids. In addition, the ECRI and healthcare facilities recognized a concern with patient comfort. Because of this concern, the ECRI changed its recommendations for blanket cabinet warmers to the 130º F (54º C).1

The ECRI recommends separate warming cabinets for blankets and fluids. If this is one cabinet with 2 compartments, each compartment must have its own temperature control. If a facility chooses to use the same cabinet/compartment for both blankets and fluids, the temperature should be limited to 110º F (43º C).1

Perioperative normothermia is a practice that is critical in promoting the well-being and comfort of all perianesthesia patients. ASPAN updated its Clinical Guideline on Hypothermia, now entitled ASPAN’s Clinical Practice Guideline for the Promotion of Perioperative Normothermia.2  The guideline includes new evidence for warming practices and promotion of optimal outcomes for patients. The reader is directed to this revised guideline, which is published in the Perianesthesia Nursing Standards and Practice Recommendations 2010-2012.3

REFERENCES

 

  1. ECRI Institute. ECRI Institute revises its recommendation for temperature limits on blanket warmers (hazard report). Health Devices. July 2009; 38(7):  230-231.
  2. Hooper VD, Chard R, Clifford T, Fetzer S, Fossum S, Godden B, Martinez EA, Noble KA, O’Brien D, Odom-Forren J, Peterson C, Ross J. ASPAN’s Evidence Based Clinical Practice Guideline for the Promotion of Perioperative Normothermia. Journal of PeriAnesthesia Nursing. October 2009; 24(5): 271-287.
  3. American Society of PeriAnesthesia Nurses. Perianesthesia Nursing Standards and Practice Recommendations 2010-2012. Cherry Hill, NJ:  ASPAN; 2010. Pages 24-45.

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Q:  What is the national trend for being able to wear personal, home-laundered scrubs to work in the PACU?

A:  Standard II - Environment of Care, found in the 2006-2008 Standards of Perianesthesia Nursing Practice, states:  "Personnel and visitor dress codes are determined by proximity and frequency of access to operating rooms."1 Unfortunately, no other recommendations in the Standards address attire worn by perianesthesia personnel.

In 1999, the Centers for Disease Control and Prevention (CDC) published a "Guideline for the Prevention of Surgical Site Infection". This guideline indicated there were no well controlled studies relating surgical site infections to laundering of scrubs. Where and how to launder scrubs was described as an unresolved matter, and no specific recommendation was issued.3 This implies that scrubs laundered at home and worn from home do not pose a risk to patients. It also suggests that, at the end of the day, those same scrubs do not pose a health threat to the home environment.

In 2003, the CDC and the Healthcare Infection Control Practices Advisory Committee issued guidelines for infection control in healthcare facilities. Although clothing contact is not known as a significant mechanism for transmission of pathogens, the guidelines recommend control measures to prevent healthcare associated infections related to contaminate clothing founded in hygienic principles, common sense, and consensus.2 When clothing becomes contaminated with blood, emesis, urine, or any other body fluid, the clothing should be immediately removed and laundered at the healthcare facility.2

The Association of PeriOperative Registered Nurses (AORN) does not support home laundering of surgical attire, citing a lack of evidence related to safety of healthcare workers, their families, and patients.4  AORN recommends that all reusable surgical attire, such as scrubs, cloth hats, and warm-up jackets be laundered after daily use in a facility approved and monitored laundry.4  AORN further advises that when healthcare workers are required by a facility to launder surgical scrubs at home, suggested measures for laundering the items should be observed. These include, but are not limited to:  use of an automatic washer and hot air dryer; washing the scrubs separately and as the last load of wash; promoting microbial kill with a water temperature above 110° F; and the appropriate use of detergent and chlorine bleach.4

Regarding the use of scrubs by the perianesthesia nurse, a general survey of clinical practice constituents from across the country revealed wide variations in opinion and practice related to scrubs. It is obvious that each healthcare institution has a tailored approach to handling scrubs based on knowledge of related research, associated costs, perceptions of staff and consumers, and cost/benefit breakdowns. Clearly, the current state of the evidence offers an expansive opportunity for studies on the implications of laundering methods. Such studies are needed to further support the decision process related to the question, “home scrubs or hospital scrubs?”

REFERENCES

  1. The American Society of PeriAnesthesia Nurses. Standard II:  Environment of care. 2006-2008 Standards of Perianesthesia Nursing Practice. ASPAN:  Cherry Hill, NJ, p. 13, 2006.
  2. Centers for Disease Control and Prevention and the Healthcare Infection Control Practices Advisory Committee. Guidelines for environmental infection control in health-care facilities. Available at www.cdc.gov/ncidod/dhqp/pdf/guidelines/Enviro_guide_03.pdf. Accessed June 11, 2007.
  3. Belkin NL. Home laundering of soiled surgical scrubs:  Surgical site infections and the home environment. American Journal of Infection Control, 29(1):  February 2001.
  4. Association of periOperative Registered Nurses. Recommended practices for surgical attire. AORN Journal, 81(2):  February 2005.

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Q:  What research has been done on temporal artery thermometers, and how accurate are they compared to tympanic thermometers?

A:  This is definitely a hot topic. The current research is primarily funded and conducted by the device manufacturer and industry. When searching the manufacturer's Web site, one finds that the company has a medical division with several articles listed on the site. Several articles are presented, and one summary article refers to a number of studies. One pilot study was presented by Steve Baumgart, M.D and colleagues, in May 2001 at the American Pediatric Society and the Society for Pediatric Research.1 This study compared infrared thermometry scanned over the temporal artery to digital axillary thermistor in premature neonates, and concluded that infrared temporal artery scanning makes repeated temperature assessment during incubation and rewarming easy to perform and it better reflects premature babies’ true core temperature while being less invasive than deep rectal or esophageal temperature monitoring.1

Another study conducted at Children's Hospital in Boston compared the temporal artery thermometer with the tympanic thermometer, and found the temporal method significantly more accurate.1 A Massachusetts General Hospital study favorably compared the temporal artery thermometer with temperatures measured using a pulmonary artery catheter in adults.1

One reason for abnormal readings most frequently cited with the use of temporal artery thermometer is user error. Moving the thermometer too quickly across the patient's forehead or breaking contact with the skin may result in erroneous readings. If your unit is using the temporal artery thermometer, your biomedical department may need to purchase a calibration kit in order to routinely check temporal artery thermometers for accuracy.

Based on the electronic mail exchanged among our ASPAN members writing to the Clinical Practice Committee, it appears that most perianesthesia nurses currently using temporal artery thermometers do not want to give them up. While we acknowledge that more studies on the accuracy of infrared temporal artery thermometry in the perianesthesia patient population are required in order to validate this method as an evidence based practice, we nurses do like the relative ease and noninvasive features.

Thanks to Susan Russell, BSN, RN, JD, CPAN, CAPA, for her contribution to this response.

REFERENCE

  1. Exergen Corporation. (2005). Independent Assessment of Temporal Artery Thermometry:  Summary. Accessed November 18, 2006 at www.exergen.com/medical/eductr/clinicallyproven.html.

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Q:  Regarding the standard about when to implement medical-surgical restraints -- when does the standard apply?

A:  From what we understand, if the use of restraint is part of the customary post procedure care the standard for restraint does not apply. It is advisable to visit The Joint Commission (TJC) Web site (www.jointcommission.org) to review their restraint standards. Type “restraint” into the search box, then select the “Restraint and Seclusion” link, which leads to a frequently asked questions page containing restraint use information.

The Joint Commission lists some exceptions to the applicability of the Behavioral Health Care Restraint and Seclusion Standards. According to TJC, “The standards for restraint and seclusion do not apply to the following:  The use of restraint associated with acute medical or surgical care, which is covered under standards PC.11.10 through PC.11.100.”1

Regarding the use of restraints for protection of surgical and treatment sites in pediatric and adult patients, TJC indicates the standards do not apply to usual “practices that include limitation of mobility or temporary immobilization related to medical, dental, diagnostic, or surgical procedures and the related post-procedure care processes.”2  Examples of the usual practices include:  protection of surgical and treatment sites in pediatric patients; radiotherapy procedures; intravenous arm boards; and surgical positioning.2

Many facilities consider short term use of restraint to protect tubes and lines during the recovery process to be medical immobilization, and in this situation do not implement the Behavioral Health Care and Seclusion Restraints standard and interventions. However, in many perianesthesia settings the staff may try to avoid the application of restraints. This is often accomplished by staying at the bedside, talking with the patient, and offering some pain medication and/or sedation. Once a patient emerges from anesthesia, but continues to need restraint to keep from pulling at lines or tubes, some institutions may require the initiation of restraints protocols.

Thanks to Clinical Practice Committee member Jan Lopez, BSN, RN, CPAN, CAPA, for her contribution to this response.

REFERENCES

  1. The Joint Commission. Revision to the Introduction to the Standards for BHC Restraint and Seclusion. Available at www.jcrinc.com/6653/. Accessed March 28, 2007.
  2. The Joint Commission on Accreditation of Healthcare Organizations. Accreditation Manual for Critical Access Hospitals, 2nd ed. Joint Commission Resources:  Oakbrook Terrace, IL. PC-22, 2005.
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Q:  Does ASPAN have a position on dose ranging of medications? If so, what is it?

A:  The ASPAN Standards do not specifically address this issue. Resource 7, titled “ASPAN Pain and Comfort Guideline”1 recommends a multimodal approach for pain management in Phase I PACU. This subject is a challenge because regulatory agencies, boards of nursing, and hospital policies usually address this issue and thus ASPAN has a broad statement in Resource 7 stressing the importance of assessment, intervention in multimodal therapy, and reassessment. In addition, ASPAN offers “A Position Statement on the Safe Administration of Medication.” This statement is posted for reference on the ASPAN Web site.

The ASPAN Standards do not describe specific interventions, such as correlating medication doses to pain scales. ASPAN’s pain guidelines basically follow the World Health Organization pyramid of mild to moderate and moderate to severe, and stress the importance of a multi-modal approach. In a recent article, a discussion concerning data reporting between 1995 and 2003 indicated that 276 sentinel events involved a 21% medication error rate related to opioids administration, and the overwhelming majority of these opioid errors resulted in death.2  However, it could not be determined whether range orders contributed to the events, or in what environment of care the errors occurred.

Manworren2 also cites a consensus paper published by the American Society for Pain Management Nursing and the American Pain Society. This document stresses the importance of the critical judgment and empirical knowledge of a nurse in determining the right dose of the right drug to relieve the patient’s pain.

Special recognition goes to Maureen McLaughlin, MSN, RN, CPAN, CAPA, for her contributions to this response.

REFERENCES
  1. American Society of PeriAnesthesia Nurses, Resource 7, 2004 Standards of Perianesthesia Nursing:  38-41. ASPAN:  Cherry Hill, NJ, 2004.
  2. Manworren R. A call to action to protect range orders:  A consensus statement supports this important nursing responsibility, American Journal of Nursing, 106(7):  p. 65, 2006.

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Q:  Can LPNs work in the PACU if they are qualified (such as having BLS, ACLS, hemodynamic courses, arrhythmia courses, starting IVs, drawing blood, and working PACU for years)?

A:  In reference to the question regarding what functions LPNs are allowed to do, ASPAN does not have a standard or position statement specific to the role of LPN in the PACU setting, regardless of the type of surgical facility. We do recommend that you look at your state board of nursing Website for some guidance. Each state has specific rules and regulations regarding the use of practical nurses, so this would be your best resource. The functions the LPN would be allowed to perform would be dictated by the state board regulations, as well as your facility's policies.

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Q:  How long do you need to observe a patient who has had reversal of a benzodiazepine with flumazenil (Romazicon)?

A:  Your question surrounded standards regarding discharge of Phase II patients after receiving flumazenil. The Standards of Perianesthesia Nursing Practice does not address this specifically. There is a resource in the standards that addresses "The Role of the Registered Nurse in the Management of Patients Undergoing Sedation for Short-Term Therapeutic, Diagnostic or Surgical Procedures". It covers management and monitoring, but really does not discuss specific medications.

The single point that needs to be kept in mind is the half-life of all the medications that were administered. According to Michael Kost, in his book "Moderate Sedation/Analgesia", flumazenil has a half-life of 30-45 minutes. The duration of action for the benzodiazepines that flumazenil reverses can last hours equal to the patient’s age (diazepam), or one to five hours for midazolam. In determining the appropriate length of time to monitor the patient who received flumazenil, the age of the patient and renal and liver function need to be taken into consideration. Dosages of the administered benzodiazapines will also need to be considered as well as why the flumazenil was administered. Was it because of respiratory depression or was it to wake the patient up a bit more quickly to move them to the recovery area and free up the procedure room for the next patient?

There is no easy answer for the length of time the patient needs to be monitored in the Phase II area. Your facility policy will give you some guidance and, when in doubt, seek input from the anesthesia provider and obtain an evaluation regarding the safety of releasing the patient to a responsible party. Another good resource is Cecil Drain’s book, "Perianesthesia Nursing:  A Critical Care Approach". Lastly, try the 2005 edition of the "Practical Guide to Moderate Sedation/Analgesia", written by Jan Odom-Forren and Donna Watson and published by Elsevier. Your hospital library may have these books if you don’t keep reference copies on your unit.

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Q:  What does ASPAN say about the standards of L&D nurses obtaining and maintaining ACLS certification?

A:  ASPAN is the Society that represents perianesthesia nurses working in the preanesthesia phase, postanesthesia care units, ambulatory settings, extended observation settings, special procedures (cardioversion, ECT, endoscopy, invasive radiology), pain management, etc. The assumption is that the above question refers to L&D nurses who recover patients that have had general or regional anesthesia after a C-section. However, relative to L&D nurses who care only for the laboring patient or a patient who has delivered normally under regional anesthesia, ASPAN has no such requirement (to obtain/maintain ACLS?).

ASPAN's Standard III addresses Staffing and Personnel Management. With regard to ACLS/PALS certification it states:  "The professional perianesthesia nurse providing Phase I level of care will maintain a current Advanced Cardiac Life Support (ACLS) and/or Pediatric Advanced Life Support (PALS) provider status as appropriate to the patient population served."

ASPAN’s Standard III also:  “recommends that the professional perianesthesia nurse providing Phase II level of care will maintain a current Advanced Cardiac Life Support (ACLS) and/or Pediatric Advanced Life Support (PALS) provider status as appropriate to the patient population served."

Phase I is defined as "the immediate postanesthesia period" during which time "basic life-sustaining needs are of the highest priority and constant vigilance is required ... as the needs of the patient are neither minimal nor episodic." “Phase II level of care focuses on preparing the patient/family/significant other for care in the home, extended observation, or care in extended care environment” (i.e. admission in this case). It is not the "1-hour" time frame, but the meeting of criteria that is essential.

Could this standard be met in another way? Yes, it can:  when a CRNA or physician ACLS provider stays in the room with the L&D nurse the entire time until the patient reaches the predetermined criteria for discharge.

Thanks to Nancy O’Malley, MA, RN, CPAN, CAPA, for her contribution to this response.

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Q:   Looking for a method to calculate IV fluid replacement for children and adults for the NPO hours, operative and post anesthesia period?

A:   Adult fluid replacement:

Three part formula for deriving amounts of fluid to be replaced:
A. Deficit is defined as the time the patient is NPO to the time surgery begins
  1. 4 ml/kg/hr for the first 0-10 kg
  2. 2 ml/kg/hr for the next 11-20 kg
  3. 1 ml/kg/hr for weight greater than 21 kg
B. Maintenance is defined as the time of incision to closure (dependent on the type of surgical procedure)
  1. Eye surgery, extremity procedure 5 ml/kg/hr
  2. Mastectomy 8 ml/kg/hr
  3. Minor abdominal procedure 8-10 ml/kg/hr
  4. Laparotomy/resection, thorocotomy 12 ml/kg/hr
  5. Extensive procedure 15-20 ml/kg/hr
C. Blood replacement:  ml/ml for blood replacement plus 3 ml/ml crystalloid to estimated blood loss or 1 ml/ml of volume expander such as albumin
Schedule for replacement during the surgical procedure: 
A. First hour:  ½ the deficit + maintenance + blood replacement
B. Second hour:  ¼ the deficit + maintenance + blood replacement
C. Third hour:  ¼ the deficit + maintenance + blood replacement

REFERENCE

ASPAN, Redi-Ref 2004:  Ambulatory/PACU/Pediatric (Ireland, D, Ed.). 90 Frontage Road, Cherry Hill, NJ, p. 72, 2004.

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Q:  How can patients with multi-drug resistant organisms (MRSA, VRE, etc.) be cared for in PACU? Do they need to be in an isolation room, recovered in the OR, returned to the patient room for Phase I level of care?

A:  ASPAN's Resource 14 for Infection Control is in the 2006-2008 Standards of Perianesthesia Nursing. The Resource offers general guidelines and stresses throughout that each facility must have an infection control plan. The perianesthesia area must follow that plan while using Resource 14 as a reference for adaptation to the PACU and Pre-op setting as appropriate.

Regarding contact isolation, it is a given that Standard Precautions are used on all patients. According to Resource 14:  ”Contact Isolation should be instituted for patients known or suspected to be infected with epidemiologically important microorganisms that can be transmitted by direct contact during procedures that require touching the dry skin or indirect contact with items in the patient's environment. (VRE, enteric infections, contagious skin infections such as impetigo, abscesses, scabies, and MRSA when institution policy considers it to be of special or epidemiological significance)”. This statement allows each institution to make its own policy and determine if these infections are of special significance requiring special precautions and handling.

Resource 14 further states:  "Place the patient in a private room when department or facility policy mandates. Wear gloves when entering the room and remove gloves before leaving. Wear a gown when entering the room if clothing will have contact with the patient or any items in the patient's environment . . . etc.”

The Resource recommends using disposable equipment or dedicating equipment to the patient. It also recommends that you ensure that multiple use patient items are cleaned using the facility approved disinfectant method.

Resource 14 states:  "If the policy (facility) allows patients in main PACU, follow the same precautions using gloves and gown with one nurse to one patient initially. Nurse may have a second patient if the acuity of the two patients allows time for the nurse to remove gloves and gown, and wash hands between patients."

Thanks to Helen Buss, BSN, RN, CPAN, for her contribution to this response.

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Q:  What is the definition for Phase I and Phase II?

A:  The best resource for this question is the 2006-2008 ASPAN Standards of Perianesthesia Nursing Practice, which you can purchase from the ASPAN Website. Having said that, Phase I and Phase II are defined as follows in Resource 3 of the 2006-2008 Standards of Perianesthesia Nursing Practice, “Patient Classification / Recommended Staffing Guidelines” (also available on the ASPAN Website).

Phase I Level of Care:  The professional perianesthesia nursing roles during this phase focus on providing postanesthesia nursing care to the patient in the immediate postanesthesia period, and transitioning them to Phase II level of care, the inpatient setting, or to an intensive care setting for continued care.

Phase II Level of Care:  The professional perianesthesia nursing roles during this phase focus on preparing the patient/family/significant other for care in the home, extended observation level of care or the extended care environment.

Thanks to Terry Clifford, MSN, RN, CPAN, for her contribution to this response.

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Q:  What are the criteria for discharging a patient following spinal anesthesia?

A:  The question about discharging patients that have received spinal anesthesia surfaces frequently. This is a concern in today’s healthcare world of:  increased caseload volume from more patients requiring surgical intervention; a shortage of competent PACU nurses; limited bed space in Phase I and II; concerns for adequately addressing patients’ comfort and safety; and managing our financial budgets. In reviewing recent literature, it was interesting to note that the first question we must answer is, to where are we planning to discharge the patient?

If it is to an in-house nursing unit, there are recent studies that suggest patients can be discharged when the following criteria are met:  sensory blockade lower than T10, minimal movement of the lower extremities, and no need for fluid resuscitation. However, most of us are still following the standard discharge criteria of stable adult patients, able to stand, walk and void following spinal anesthesia if they are going home or to another nursing unit.

If you do not use a patient classification scoring system to determine “Readiness for Discharge” for all patients in your units, I would suggest that your unit consider doing so, beginning with Resource 4 “Criteria for Initial, Ongoing and Discharge Assessment and Management” found in the 2006-2008 ASPAN Standards of Perianesthesia Nursing. There are several other scoring systems that are commonly utilized by many PACUs as they were published by their authors or adapted to meet the specific needs of a unit’s patient population. The Postanesthesia Recovery Score of Aldrete and Kroulik1 is an excellent Discharge Scoring System, as is The Short-Stay Surgery Discharge Score (SSSDS) noted in that same article.1  For optimal safe patient care your unit needs to adopt or develop a patient discharge scoring system and have it approved by your facility for all patients that receive care there, including patients receiving spinal anesthesia.

Thanks to Barbara Hannah, EdD, MSN, RN, CPAN, for her contribution to this response.

REFERENCE

  1. Mortensen M. Discharge score for surgical outpatients. American Journal of Nursing, 86(12):  pp. 1347-1349, December 1986.

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Q:  Must a registered nurse accompany patients being transferred from PACU?

A:  Resource 10, Safe Transfer of Care in the 2006-2008 Standards of Perianesthesia Nursing Practice states, among other things:

  • “The professional nurse determines the mode, number and competency level accompanying personnel based on patient needs.”
  • “The professional nurse assures the availability of appropriate transportation of the patient from the facility.”
  • “The patient will be discharged with a responsible adult.”
  • “A plan exists for those patients who do not have an accompanying responsible adult or reliable transportation.”
  • “An appropriate means of transportation from a freestanding facility to a full service hospital will be used in emergent and non-emergent situations.”
  • “A professional perianesthesia nurse should accompany patients that:
    • Require continuous cardiac monitoring
    • Require evaluation and/or treatment during transport (i.e., vasopressor infusions or pulse oximetry)”
  • “The professional perianesthesia nurse determines the appropriate equipment and supplies needed for transport”
  • “Transport personnel will remain with the patient until the receiving unit personnel are at the bedside to assume responsibility for the care of the patient.”
  • “Patient identification is verified per institutional protocol.”

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Q:  What does ASPAN say about families visiting in PACU?

A:  ASPAN has taken the position to support family visits in PACU. Guidelines certainly need to be in place to assist with incorporating family visits in the Phase I level of care. There is a Position Statement included in the 2006-2008 Standards of Perianesthesia Nursing Practice that is available on the ASPAN Home page. It can be found under Clinical Practice and is titled “A Position Statement on Visitation in Phase I Level of Care.”

In units that have adopted family visitation practices the results have been positive for all. It is reassuring to family members to see their loved ones and patients also find it comforting. This practice requires education for the family and measures taken to provide patient confidentiality and privacy.

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Q:  What are the staffing recommendations for Phase I level of care? Is it necessary to have two nurses present?

A:  The answer to these questions can be found by returning to the ASPAN home page. Click on the Clinical Practice button at the top of the page and “pull down” to Patient Classification. In Resource 3 of the 2006-2008 Standards of Perianesthesia Nursing Practice, “Patient Classification/Recommended Staffing Guidelines”, you can read the Resource in its entirety and print if off for reference.

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Q:  How many PACU beds should there be for each OR?

A:  In Cecil B. Drain’s fourth edition of Perianesthesia Nursing:  A Critical Care Approach you will find some recommendations. It states:  “For an inpatient hospital PACU that serves a combined patient population of inpatients and same-day admission patients, a ratio of 1.5 to 2 PACU bays per OR is necessary to safely care for the patient”. For a same day surgery setting “with a limited number of surgical services and types of procedures, 2.5 to 3 PACU Phase I and PACU Phase II (combined) bays are necessary”.

Things to keep in mind are the type of surgeries done and the type of anesthesia generally preferred by the anesthesia providers. Will most of the patients have a high acuity and require prolonged monitoring and observation? Will most of the anesthetics be regional blocks with sedation and be “fast tracked” to the Phase II level of care? When these questions can be answered, it becomes easier to determine the number of beds needed for a particular institution.

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Q:  What are hospital PACUs doing regarding sending patients back direct to ICU from the OR, especially if the patient came from the ICU? If the patient goes back to ICU must a PACU RN recover the patient there?

A:  This issue has been debated for years, and ultimately, it is up to each hospital to decide based on staffing of both PACU and ICU. ASPAN Standards cannot dictate where the ICU patient will be recovered or by whom. It really is imperative to consider the needs of the patient and how much care he/she will require. Collaboration between the two units can clearly benefit both units in most hospitals.

Frequently, if the patient came from ICU and is returning to ICU intubated, the ICU nurse recovers without a PACU nurse unless the patient is very unstable and ICU has limited available staff. If a PACU nurse is available, the PACU nurse can help as needed.

If the patient is extubated, some anesthesia departments prefer that a PACU nurse care for the patient either in ICU or PACU. During the day, the ICU patients may come to the PACU as PACU staffs have co-workers present to assist as needed. When on call, most prefer to recover the patient in the ICU as there are more resources immediately available.

There are discussions about having ICU nurses recover all ICU patients. There are two drawbacks that will arise:

  1. The PACU staff cannot keep high ICU skills levels (PACU is a "critical care unit") unless they care regularly for ICU patients.
  2. ICU nurses must possess the same level of expertise in managing the immediate post-op patient as the PACU staff (we are a "specialty"!) so ICU nurses must have specialized education and competency assessments related to Phase I level of care.
It is difficult to give a straight-forward response to this question as there are many variables that caregivers must consider. Who is the best, safest, most qualified person to care for each patient at that particular point in time? The anesthesia provider, and sometimes the surgeon, will determine where the patient ultimately receives immediate post anesthesia care.

Thanks to Nancy O’Malley, MA, RN, CPAN, CAPA, for her contribution to this response.

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Q:  Is it necessary for a cardiac rhythm strip to be recorded and placed with the PACU record?

A:  Resource 4 in the ASPAN Standards states that the cardiac monitor rhythm must be documented. The Standards do not elaborate as to the specifics of how the rhythm is documented, i.e., a rhythm strip. Many facilities place a rhythm strip in the flow sheet, as well as document the rhythm. If the rhythm changes, the nurse can then place a second strip in the flow sheet showing the different rhythm as well. If there is an issue with placing a rhythm strip in the chart, you might ask how the nurses have demonstrated competency in ECG interpretation so that nurses’ interpretation of the rhythm without the actual rhythm strip can be validated.

Anesthesia providers will often bring strips from the monitor obtained during surgery, especially if some change occurred. Rhythm strips are frequently obtained upon arrival in the PACU. The timing element of the obtaining a rhythm strip postoperatively is that anesthesia can have harmful cardiac side effects, especially in elderly patients, and the rhythm strip may capture the effect. It is also helpful for documentation purposes. When a nurse is relieved for a break or handing over his/her assignment, it is helpful to have documentation to compare with the present monitor pattern in case some change has occurred during the postoperative course.

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Q:  Looking for guidelines from ASPAN for recommended frequency of vital signs in Phase I level of care.

A:  ASPAN’s 2006-2008 Standards of Perianesthesia Nursing Practice does not specify how frequently vital signs need to be taken. Frequency is patient specific according to stability of condition and degree of variance from baseline. Most institutions have a policy to take vital signs every five minutes for the first 15 minutes, and then every ten to fifteen minutes for the duration of the stay depending on patient stability and return to baseline. If the patient is very unstable, perhaps on vasoactive drips, etc., the frequency will be at least every five minutes until the patient is more stable. It is unusual to find a time span greater than fifteen minutes in Phase I PACU unless the patient is a boarder or awaiting transfer to another area.

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Q:  What do we need to do to be in compliance with standards for follow-up phone calls after outpatient surgery?

A:  The Joint Commission standards do not require a follow-up phone call. Standard PC.2.20 from the 2007 Comprehensive Accreditation Manual for Hospitals and the 2006 Comprehensive Accreditation Manual for Ambulatory Care allows an organization to define what data and information is gathered during assessment and reassessment. PC.2.150 allows organizations to determine timeframes for reassessment based on patient needs and the care, treatment and services provided. The organization must be able to justify the efficacy of the mechanism chosen based on the patients it serves and the services or care provided.

In practice, most organizations, especially those performing surgical and/or invasive procedures on an outpatient basis, find the post-procedure phone call follow-up to be helpful from both a timeliness and patient-focused perspective. Organizations that have chosen to adopt the phone call reassessment must also consider how it will be accomplished for patients requiring follow-up on weekends or at other times when staffing is an issue.

Additionally, LD.3.20 from the same manuals, requires that patients with comparable needs receive the same level of care, treatment, and services throughout the organization. The question an organization must ask in that situation is whether or not the intensity of reassessment for outpatient surgical patients is comparable to that for other patients in similar situations (e.g., inpatients, post-procedure outpatient interventional radiology)?

In the 2006-2008 Standards of Perianesthesia Nursing Practice, Resource 4 “Criteria for Initial, Ongoing, and Discharge Assessment and Management” states:  “Discharge Assessment:  Extended Observation - The Registered Nurse will adhere to institutional policy for patient reassessment following discharge. How this is done will be determined by institutional policy and procedure.”

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Q:  What are the recommendations for PACU nurses regarding ACLS and PALS?

A:  This is addressed in Standard III in the 2006-2008 Standards of Perianesthesia Nursing Practice, “Staffing and Personnel Management”. It states, “The professional perianesthesia nurse providing Phase I level of care will maintain a current Advanced Cardiac Life Support (ACLS) and/or Pediatric Advanced Life Support (PALS) provider status, as appropriate to the patient population served.”

At one time, the phrase “or equivalent” was included in this statement, but this was deleted in the 2002 Standards. The decision to delete was made when the AHA ACLS protocols were based on evidence. Research is ongoing, with changes made in the protocols as evidence supports new recommendations for practices, making it difficult for institution developed programs to reflect these changes in a timely fashion.

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